306001749-4-29-2021-22-AS-LADS-C2RNUB-20210506104600

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306001749
Report Date: 04/29/2021
Date Signed: 04/29/2021 02:40:54 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/30/2020 and conducted by Evaluator Albert Marin

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200930165653

FACILITY NAME:	ARVILINH HOME CARE		FACILITY NUMBER:	306001749
ADMINISTRATOR:	ARVIN BUMANGLAG		FACILITY TYPE:	740
ADDRESS:	9351 MELBA DRIVE		TELEPHONE:	(714) 643-9077
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92841
CAPACITY:	6	CENSUS: 6	DATE:	04/29/2021
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Administrator Arvin Bumanglag		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff refused to administer medication to resident.
Staff is not treating resident with dignity and respect.

INVESTIGATION FINDINGS:

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As precautionary measures during the Coronavirus 2019 (COVID 19) pandemic, Licensing Program Analyst (LPA) Albert Marin conducted an unannounced teleconference visit with Administrator Arvin Bumanglag. The purpose of the teleconference is to deliver the findings for the complaint investigation initiated by LPA James August and completed by LPA Marin.

On September 30, 2020, The Department received a complaint alleging that the staff refused to administer medication to the resident. In 2019, Resident 1 (R1) was admitted in the facility with primary diagnosis of Depression and Chronic Pain Syndrome. To manage pain, R1 was prescribed with medications which included gabapentin for nerve pain; hydrocodone acetaminophen as needed for moderate pain; and acetaminophen and ibuprofen as needed for mild pain. Per interviews, Resident 1 refused to answer questions on medications. Two out of two witnesses denied that staff refused to assist them with medications when needed. Interviews with other pertinent parties did not support the allegation.
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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert Marin	TELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20200930165653

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ARVILINH HOME CARE	FACILITY NUMBER: 306001749
	VISIT DATE: 04/29/2021

NARRATIVE

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On September 30, 2020, The Department also received another allegation that staff is not treating the resident with dignity and respect. Per interviews, Resident 1 refused to answer questions on any incident related to the allegation. Two out of two witnesses stated that they felt safe in the facility; and denied any incident related to the allegation. File review indicated that staff received training on resident rights.

Based on the information gathered during the investigation which involved interviews, observation and review of all documents obtained, The Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred. Thus, the allegations that staff refused to administer medication to the resident, and that staff is not treating resident with dignity and respect, are deemed UNSUBSTANTIATED.

LPA Marin conducted an exit interview and read this report to Administrator Arvin Bumanglag. Copy of this report will be provided via email. As agreed AD will acknowledge this receipt.

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SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert Marin	TELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021

LIC9099 (FAS) - (06/04)

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